The Department of Veterans Affairs and the Centers for Medicare & Medicaid Services reported a combined $24.3 billion in estimated improper payments across two health programs in fiscal 2025, according to the Government Accountability Office.

VA estimated $608 million in improper payments in Community Care, equal to 2.4% of that program's outlays. CMS estimated $23.7 billion in improper payments in Medicare Advantage, or 6.1% of outlays.

Graphic lists 608 million dollars for VA Community Care and 23.7 billion dollars for Medicare Advantage.
Fiscal 2025 improper-payment estimates were $608 million for VA Community Care and $23.7 billion for Medicare Advantage.Boho News graphic from cited primary dataView source

An improper payment is not automatically fraud. The category can include overpayments, underpayments, payments made without enough documentation and other errors; GAO assessed payment-error controls and fraud risk as related but distinct issues.

GAO found that both agencies had processes to identify root causes of improper payments. VA also had corrective-action plans that the watchdog said adequately addressed identified causes for the years reviewed.

CMS's Medicare Advantage improper-payment rate had remained steady, GAO said. Its corrective plans were not detailed enough, and the agency lacked a detailed plan to clear a backlog of Risk Adjustment Data Validation audits used to identify and recover improper payments.

Neither agency had completed a comprehensive fraud-risk assessment for the program GAO reviewed. VA had taken some fraud-risk steps, but GAO said they did not cover all key elements of its framework.

Graphic lists three open GAO recommendations, one for VA and two for CMS.
GAO made three open recommendations: one to VA and two to CMS.Boho News graphic from cited primary dataView source

GAO issued three recommendations: VA should conduct a comprehensive Community Care fraud-risk assessment, while CMS should create a detailed RADV-audit plan and conduct a Medicare Advantage fraud-risk assessment. All three were open when GAO published the report.

VA concurred with its recommendation. CMS neither agreed nor disagreed with its two recommendations and described actions it believed addressed them; GAO maintained that additional action was warranted.

The accountability measures are whether the agencies complete the assessments, reduce the audit backlog and publish evidence that corrective plans lower error rates. The reported improper-payment estimates do not establish the amount lost to fraud or the amount that can be recovered.